Population health management (PHM) is the use of management strategies to improve the health and wellbeing of a defined population, to improve quality, to reduce costs, and to improve workforce productivity (Counte, 2019, p. 423). PHM is focused on creating and improving healthcare cost outcomes. The approach needs to be multi-pronged and at the individual and population levels.

Among countries that belong to the Organization for Economic Cooperation and Development (OECD), four main factors are triggering the need for a population health focus: (1) the aging population; (2) the increased prevalence of chronic conditions; (3) the need to contain costs of care, improve efficiency, and strengthen organizational performance; and (4) the desire for patient-centered care (Counte, 2019, p. 425). To be effective, PHM should incorporate disease management, health, and wellness management, as well as care management technology like electronic health records (EHRs).

Issues

The average age of the world population is rising, placing a challenge on health systems to manage certain conditions such as dementia, fall prevention, and diabetes to name a few. Multiple strategies for risk assessment, prevention, and reduction need to be designed and implemented (Counte, 2019, p. 427). Improvements are needed in health technologies to combat disparities and gain a better understanding of disease progression through the collection and analysis of data. Continued improvement in medical devices and technologies that can provide real-time information allowing providers to communicate more efficiently. Coordination of care is essential to managing chronic disease and illness. PHM must effectively implement care management activities, starting from the systematic care assessment, to care plan development, to care monitoring, to care evaluation (Counte, 2019, p. 428). Better use of social media to relay information at a global level. Development and use of predictive analytics and decision support software to guide changes or improve performance. Participating in the global genome collaborative project to improve outcomes for disease that share common genes.

Cultural Considerations

Health inequities between and within populations are most often the result of SDOH (Counte, 2019, p. 432). Living and living conditions and access to quality healthcare is not the same for everyone. If one SDOH of health is lacking (education), it is likely that the other SDOH are lacking as well (housing, employment, access to medical care, etc.). Cultural competence is more than just looking at SDOH. It is vital to delivering care that is in-line with the populations beliefs and values and this extends beyond race or ethnic groups to those with disabilities, the LGTBQ+ community and more. Sociodemographic and socioeconomic characteristics continue to determine an individual's access to safe, quality care, and as the definition of diversity evolves to include gender identity, sexual orientation, and socioeconomic, veteran, and disability status, more people are affected (Bhatt, Bathija, 2018, p. 1272). More than 1,500 hospitals, roughly 25% of all U.S. hospitals, have pledged to take action on specific goals to eliminate health care disparities, led by the AHA's Institute for Diversity and Health Equity (Bhatt, Bathija, 2018, p. 1272).

Global Views

Only a limited number of theoretical and substantively meaningful frameworks have been developed to illuminate how ecological correlates and their dynamics influence the health of different ethnic populations around the globe (Wan 2010) (Counte, 2019, p. 430). At the macro-level, population health is influenced by four components known as POET.

1. Risk identification of population health needs (P)

2. Innovative health organizational structure (O)

3. Design of healing environments (E)

4. Adoption and diffusion of technology (T)

At the micro-level, determinants of health are influenced by personal attributes such as predisposing factors (e.g., demographic characteristics, attitude, perception, behavior propensity, cultural preference), enabling factors (e.g., family income, health insurance coverage, access to primary care, health system-related factors), and need-for-care factors (e.g., health status, diagnostic conditions, severity of illness, perceived health) (Counte, 2019, p. 430). Global health research needs to be conducted at both the macro and micro levels and consider such factors like individual, ecological, and contextual.